Will Improvement be the new Nokia? An open letter to NHS Improvement Leaders

An Open Letter for NHS Improvement Leaders

Look around you - how many people are using a Nokia phone?

My first mobile phone, in the 1990's, was a Nokia. I wish I'd kept it as it sells on eBay now for more than it cost at the time. However, it's now perceived as an art form, not as a workable option for making phone calls.The demands on mobile technology have also moved on - I use my smartphone less for making calls and more for reading email and playing Bejewelled.

What happened is the context changed. The markets developed, the customers upped their expectations. Nokia, very successful in the early days of mobile technology got comfortable with their success. They became blind to the shifts and the need to dump their favourite (and no doubt hotly promoted in-house) technologies.

The basic concepts of mobile technology has not changed much - but the products have changed significantly.

The basic concepts of what we understand as quality improvement have not changed much since the days of Deming - what hasn't developed much are the products to implement change. TQM has been rebadged, with minor modifications into Lean, which has been rebadged, again with minor mods into a variety of corporate improvement programs. And so on.

Now, I'm not suggesting we throw out all the good things we know about improvement (I can't bring myself to call it improvement science" - it isn't a science.)  We can keep the basic concepts. However, I do feel strongly that retaining "legacy products and programs" is lazy. If you feel the need to say "we need to retain what works" then think through how that sounds to NHS staff - and what it reminds you of.*

Every improvement product designed in and for the NHS has been a consequence of the context within which it was designed, then implemented. The NHS is making enormous changes  both structurally, conceptually and clinically.  Retaining "legacies" doesn't feel like support to this new context.

Be brave, NHS Improvers. Match the pace and scale of the changes in the NHS around you. Let go of your outdated models, methods, tools and products, in just the same way as thousands of NHS staff are having to do on a daily basis for the practises they believe are useful and good.. Design for the future.  Practise what you preach and get innovative - from within.  And I mean truly innovative. I don't mean coming up with an edited version an existing product, or a new framework for something. Instead, create the breakthrough applications that not only fit in the current context, but reset the whole discipline of "improvement" in healthcare. The NHS has an enormous amount of improvement experience and brainpower - use this to good effect.

Nokia missed the boat. It's trying to turn around, but playing catch up in a fast developing market is far more difficult than leading the market by designing the market - think Apple.

In April 2013 the NHS boat will sail. New structures will be in place, along with new demands that will change the face of the NHS for both staff and patients.  My hope is for "improvement" to be on the same boat, and not one of the tugs pulling in the opposite direction.


Note: * Improvers often talk about wanting others to adopt new practises and when these people don't want to, they're labelled as "resistant to change". I'm just saying...

Test, Learn, Adapt: Developing Public Policy with Randomised Controlled Trials

A good friend, Bill Russell, told me about a paper produced by the UK Cabinet Office calling for Randomised Controlled Trials for Public Policy. I was sceptical. When he told me Ben Goldacre (author of the excellent book, "Bad Science") was involved I was intrigued, and then wondered whether it was a spoof. But it isn't.

Hallelujah!

This paper is required reading. [update: new link] I commend it to you all and especially those I've been trying to convince for years that spreading improvements or innovations can have an ethical bias - how do you know it's a good and effective thing to spread?

And when you've read it - read it again. This has to be the best paper I've read for some years.

(I hope someone has passed it on to the Department of Health and the NHS Commissioning Board.)

Web 2.0 not role modelled is inauthentic

Anyone or any organisation that flies the flag of change management and improvement always has the difficult task of acting what they say, namely being a role model for what they espouse.  It is difficult to get right all the time and I certainly don't.

One positive example I have experienced is the Institute for Healthcare Improvement who, a while back, took on the challenge of improving their invoicing and payment system on the basis they couldn't teach others to do it unless they (a) were a good role model and (b) learnt from their own experience.

The worst of management consultancy is when concepts and theories from books are copied onto PowerPoint slides and then used to train others. Where the trainers have no experience of the content their audience will soon figure out the dissonance and leave the session - either physically or mentally.

In England we have a rash of NHS Improvement related organisations trying to get onto the social media bandwagon. I am all for it as I believe it is an essential tool for communicating and engaging with others. However, when the organisations involved have no official and monitored Facebook page, do not use blogs (as in few is any of their Executive Teams or Senior Staff use them), have never used a wiki, do not use RSS feeds themselves as part of their own learning, or never used a discussion forum in-house etc - then the exhortations and training comes across as inauthentic.

There are one or two NHS Improvement groups, like NHS Improvement, who are using Web 2.0 techniques to their advantage and I like the way they are starting with themselves and learning how to use them in-house, before going outside.  I am sure they will be excellent role models for the future.

Public Value in the Public Sector: Literature review and toolkit

The University of Birmingham Health Services Management Centre and the NHS Institute have completed some research on public value in the context of public services. The literature review and associated "toolkit" is available on the NHS Institute Website.

Hoorah! It is now recognised that the technical tools of change (like redesign, scenarios etc need to be combined with the more non-technical aspects such as the media, local pressure groups, politics etc.

As always, turning theory into practise is the difficult bit and I look forward to these concepts and new ideas being used.

Productivity 8: Where to find ideas for improving productivity in the NHS

This is the 8th in a series of Productivity notes by Sarah Fraser. So where do we find the "no-brainer" ideas for improving productivity in healthcare.

There is no need to start from scratch if you're looking to improve productivity in your organisation, team, ward or practice.  Many have gone before you and many have spent time writing up their experiences so you can learn from their efforts.

This is where I start looking:

1. NHS Library (or any other academic library). DO some proper searches. I do feel that starting on productivity initiatives without doing a couple of hours research is shortsighted.  Google is not enough..
2. NHS Institute for Innovation and Improvement; for NHS England there is a lot of information available.  Scotland and Wales I know have similar organisations who gather and share productivity and improvement information. The same is true for most countries which have a public sector health system
3. The Institute for Healthcare Improvement has a great deal of case studies and resources freely available

If I find nothing in the above then I will find another topic to work on. There is so much to learn from what others are doing that can make the productivity process easier that it doesn't feel worth being the one person who decides to design a research project instead of getting on with the change process.

If you have any favourite place to look for productivity ideas then please add a comment to this post.

Learning networks or social movements? Which is best for large scale change?

I'm not sure there is a specific answer as to whether learning networks or social movements are best for large scale change.  However, my personal preference is for learning networks and these are my reasons:

1. learning networks connect the people who are interested in solving the problem, and they do so in an interactive, participative and empowered way. In comparison social movements have the image of someone wanting to make something happen and in manipulating the joining in process and to an agenda they have set.
2. learning networks are about the exchange of information, discussion and both personal and group learning. Personal behaviour may change as a result of learning about something new from within a peer group. When a group discovers new knowledge and feel the creative process of doing so, they may become quite committed to then implementing changes.
3. learning networks can be direct and specific. They can be topic based or professional grouping based.
4. there is a sense of an output with learning networks. Social movements are useful in that they are purpose driven, however, learning networks to me are more concrete, pragmatic and easier to associate with outcomes and results.
5. we know learning networks work in healthcare while social movement theory is in its infancy. I am a proponent of using the existing knowledge we have to best effect.

This doesn't mean social movements are not useful, rather that I am sceptical about their ability to deliver results, especially when we know learning network can have an impact.

There is an excellent paper on Learning networks for sustainable, large scale change which is worth a read. 

6 resources for Patient Centred experience and Design (EBD)

Ensuring "involving patients" is more than rhetoric is a challenge. For any healthcare project, be it an innovation or an attempt to spread good practice and adapt evidence to work locally, engaging with patients and service users is a challenge.  This post suggest five resources to help you.


1. The Picker Institute Europe is a world leader in working with patients on a large scale and covering public, private and the voluntary sector.  Their remit is to work with healthcare providers and commissioners to:

• measure patient experience
• gather patient feedback
• analyse the findings
• develop action plans
• engage patients in service improvement
• evaluate improvements and
• communicate developments back to your Board and stakeholders.

Available from their website is a comprehensive toolkit for Using Patient Experience. It is free.

2. The USA based Institute for Patient Centred Design is unique in that it provides resources on design not only for healthcare professionals but also to patients; excellent way of practising what they preach! They have a number of documents and surveys (free) available online.

3. The Centre for Health Design has an evidence based focus. They have a number of evidence based design resources on their website and their Healthcare Leadership portal has excellent PDFs for download and access to a variety of multimedia resources. This includes an excellent review on the literature of evidence based design These are free.

4. The NHS Institute which covers the NHS in England, has a toolkit on Evidence Based Design which is available to NHS England staff (max 20 copies) for free, and £30 for copies for others. They also have a facilitator's pack available for purchase.

5. The UK Department of Health has published a toolkit on understanding detailed patient experience data. Although this does not cover design and involvement in depth it is a useful kit to help you understand what to do with the data you are presented with. 

6. The Design Council in the UK is running a project about Designing for Patient Dignity. While most of this covers the physical aspects of patient care, the case studies and design process make for interesting reading. They have published a 25 page booklet which is free to download. 

If you have any favourites I've not covered here then please leave your notes and a link in the comments on this blog.

Productive Partnering self assessment tool

The NHS Institute, working with PriceWaterhouseCoopers, developed a self assessment tool to help English Primary Care Trusts to figure out how best to create and maintain multi-sector partnerships.

The self assessment is the result of a program that aimed to reduce health inequalities which involved multiple different stakeholders coming together for the purpose of the project. The tool is aimed at groups who need to work together to deliver complex health orientated outcomes.

Getting evidence into practice is difficult enough. Doing this when there are multiple stakeholders is even more complex, risky and prone to non-delivery.  This tool goes some way to helping groups figure out how best to work with each other, with a health outcome in mind.

Online Clustered Networks Spread Behavior Change Faster

Online communities have different dynamics to face-to-face communities of practice. New research suggests that for online communities, behaviour spreads more quickly when the community is grouped into networks with overlapping connections than when left to develop more random and distant links.

If you are managing online communities then the research is worth a closer look as it may provide hints on how to design and support it so behaviour and influence can spread amongst the participants.

For communities of practice not online this clustering effect is not new. Research has been around since the 1970's which show the importance of bringing groups together geographically, thematically and/or by profession or person type. As humans we like to be with people similar to ourselves and are most influenced by those the same as us - if Joe can make the change then I will probably be able to as well.

There is a lot of buzz about social movements, mobilising and organising for change in healthcare. One of the success criteria for this work will be the depth to which those doing the organising as well as those participating understand network dynamics, and design accordingly.  Random networks are less influential.

NHS partnership working and improvement; we've been here before

A number of large scale programmes are running in the NHS in England where communities are getting together to improve health and social care services. The projects have a wide membership from mostly statutory public sector organisations but also some in the voluntary sector. As some of the strategies sounded familiar I checked the Department of Health website.

I was involved in partnership working in the NHS in the mid and late 1990's. At that time in England there were also Healthy Action Zones which seem very similar to many of the programs underway at present. It seems to topic is coming round again but with a new language and consequently a delay in making changes. There are many papers and documents available form around 2002 - 2004 which have self-assessments, methods, best practice examples, case studies and similar. I find it so disappointing that those who are responsible for the spread of good practice and large scale change feel the need to continue to reinvent wheels - thus not practising what they preach.

If you are interesting in learning what has gone on before and in adopting and adapting existing ideas for large scale change then try out these papers from the Department of Health:

Working in Partnership; developing a whole systems approach (notable because it covers productivity - and this was 2002...)

Governance in partnership checklist of good practice

If you only want what is new then try
Working with Stakeholders which is 2010